Hip Bursitis
Hip Bursitis- It’s Not Just For “Old Folks”
- Dr. Jeffrey Luebbe
More often than not, when a patient is given the news that they are suffering from bursitis in the hip, they respond with something like, “Bursitis? I thought that was for “old folks!” The truth be known, bursitis happens to people of all ages.
When hip pain presents, there is a large list of possible causes, and each presents its own peculiar set of characteristic symptoms. Injury to a lumbar nerve root (nerves that exit the lumbar spine and proceed down into the hip, groin and leg) may be one possibility. Infections in the hip joint and pelvis may also cause a patient to present with hip pain. These infections can exhibit excessive redness and heat in the area and must be treated medically. Trauma to the hip from a fall, motor vehicle accident or sudden athletic injury can cause fracture of the top of the femur (thigh bone) or the pelvis, resulting in hip pain.
Often in the case of trauma, there may be a thick, boggy-feeling swelling around the hip indicating that there is bleeding from a fractured bone or torn ligament. Tendons and muscles that begin and end in the area of the hip can be overused or injured in sports, especially in the “weekend warrior.” Avascular necrosis, a condition in which the femur head loses normal blood circulation and dies, will also generate hip pain. Osteoarthritis, which does occur in middle age and older persons, is a painful condition in which there has been a history of a previous injury which did not heal well and has left long-term damage in a joint. Osteoarthritis may occur for no apparent reason, perhaps because of a long life of overuse or even a congenital deformity. Gout, which is a condition in which there is a deposit of uric acid crystals in the joint, can created tremendous hip pain. Other arthritides classified as inflammatory arthritis may be present. Examples include rheumatoid arthritis and Reiter’s Syndrome. Having mentioned all of the above possible causes of hip pain, bursitis is the most common of all.
A bursa is a small, closed, fluid-filled sac or pouch that sits between two structures in the body to reduce friction between them. This is typically found between a tendon or muscle and a bone or ligament. With normal motion of the body, there is potential for friction to occur which would ultimately cause damage to the structures involved with that motion. It is the bursa’s function to greatly minimize that friction by providing a slippery buffer between moving parts. Bursae are found near all the large joints such as the shoulders, elbows, knees and hips. There are some 160 bursae located throughout the body, and possibly as many as 13 of them in and around the hip joint alone.
Bursitis is a condition in which there is inflammation in the bursa. This may occur because of infection, various inflammatory arthritides (such as gout, rheumatoid arthritis, etc) and trauma. Most commonly, however, it is overuse and abnormal motion that is the cause of bursitis.
There are five bursae near the hip that seem to be the most problematic. Two of these, the trochanteric bursae, are located close to the “point” of the hip – one just above and behind the point of the hip, and one just below it. If one were to bump the side of the hip into a wall while walking in a hallway, the point of that contact would be directly on or very near these two bursae. Two other bursae are located in the front of the hip joint area, and they provide protection from friction between the front side of the hip and its ligaments and the muscles that lift your thigh up and forward. A fifth burse lies on the back side of the hip joint, protecting the underside of the gluteus maximus (buttock) muscle from friction. Of these bursae, the trochanteric bursae present the majority of the problems.
Symptoms of hip bursitis typically include pain when direct pressure is applied on top of the bursa. The pain may be a sharp tenderness, or a deep dull ache. It may refer pain down the front, side or back of the thigh to the knee. Because of this, it is often overlooked and misdiagnoses as a lumbar spine problem. There is sometimes visible swelling over the side of the hip if the trochanteric bursae are inflamed. One of the most common complaints, however, is pain at night. Lying on the affected side can be extremely painful and will disturb sleep. Even laying on the unaffected side can cause the affected side to ache while sleeping.
In order to plan proper treatment, the structural and functional causes of the problem need to be addressed.
Abnormal gait (walking and moving) patterns are often a culprit. A foot and ankle that over-pronate (rolls in toward the floor) cause rotation of the lower leg and consequent rotation of the femur. This in turn causes overuse and over tightening of the external rotators of the hip, specifically the outside fibers of the gluteus maximus. These gluteus maximus fibers attach to the iliotibial tract, which is a large, wide band of tough tissue that transfers forces from the muscles of the buttock and pelvis to the knee joint. It is this iliotibial tract that rubs over the trochanteric bursae, causing bursitis.
Other muscle imbalances which involve the iliotibial tract may be causative. The tensor fascia lata is a muscle that also pulls on the iliotibial tract, along with the gluteus maximus. Abnormal movement patterns can occur and result in tightening and overactivity of the tensor fascia lata, again causing excessive tension on the trochanteric bursae. During normal walking, the iliotibial tract is pulled forward when the knee is brought forward to take the next step. Then, as the body is propelled forward, the gluteus maximus pulls the iliotibial tract backwards, over the greater trochanter (point of the hip). It is at this point that tightness of the iliotibial tract creates excessive pressure an irritation of the bursae.
Improper lifting technique for those people that do repetitive lifting is another cause. As mentioned above, when the hip is in flexion (knee forward) and then brought backward, there is pressure on the trochanteric bursae. This occurs when lifting is performed from the hip and lower back without using the legs and knees. Too much of this activity may soon cause inflammation in the hip bursae.
Tightness and over activity of the iliopsoas muscle (the deep, large muscle that pulls the thigh forward) is a major factor in bursitis in those bursae at the front of the hip. Unfortunately, in our culture, there is a tendency to sit too many hours a day with the hip flexed forward, and a lack of exercises that stretch this important muscle. As a consequence, it becomes tight and much less flexible. Additionally, while the iliopsoas becomes tight and over active, the gluteus maximus becomes lazier and inhibited, adding to the imbalance.
Lumbosacral and sacroiliac dysfunction (dysfunction of joints at the base of the spine) are major players in hip bursitis. As with any vertebral joint, and any joint in the body for that matter, a joint that does not function in its proper, normal movement range causes the muscles and tendons that move it and surround it to also function abnormally. For instance, when the ilium (the bone that makes up the outside rim of the pelvis) becomes rotated backward and fixed in that position, there is excessive stretching of the iliopsoas muscle and shortening of the hamstrings. This sets the hip bursae up for stress and irritation. Lumbar vertebrae that do not flex and extend or rotate in their normal ranges of motion create excessive stresses on the pelvic muscles, and again load the bursae with more than they can handle.
Other structural situations that can lead to hip bursitis include leg length discrepancies, increased Q angle (a genetic condition that is more common in women in which the femurs angle in to form a knock-knees stance), and osteoarthritis of the hip or knees can be factors as well.
The treatment of hip bursitis includes initial reduction of the acute pain and inflammation that is present. That can be done with ice therapy, NSAIDs, pulsed ultrasound, and interferential current modalities. Relative rest (ceasing the activities that are aggravating the condition) is necessary. When sleeping, typically laying on the back with soft support under the knees, or lying on the unaffected side with a large pillow between the knees with the hips and knees partially flexed is extremely helpful in reducing night pain and getting good rest.
In the longer run, correction of the above described imbalances is critical. Active stretching techniques used to lengthen and relax the tight tensor fascia lata, gluteus maximus, iliopsoas and iliotibial tract are extremely important. Spinal manipulation of the lumbosacral and sacroiliac joints to correct dysfunctions in these areas is critical as well. Mobilization or manipulation of the hip joint, knee joints, ankle, and feet are also very important. Correction of leg length deficiencies using heel lifts or shoe alterations, and orthotics to correct overpronation of the foot and ankle are excellent long-term solutions.
A good evaluation and workup of any hip pain is essential to rule out the more serious causes of pain. Once it is established that the bursa is the culprit, proper treatment can and should be very effective in getting rid of hip bursitis.
In order to plan proper treatment, the structural and functional causes of the problem need to be addressed.
Jeffrey Luebbe, DC, CCRD, CCSP® has practiced with Cole Pain Therapy Group since 1985. Dr. Luebbe is a Certified Chiropractic Rehabilitation Doctor and a Certified Chiropractic Sports Physician® with extensive postgraduate education in chiropractic orthopedics.